"Precious and fragile things need special handling."

[thankfuckforlife]

Who: Richie Jameson, Kevin Lawson and Quentin Lawrence
What: Plan of action
Where: Children's Unit, Mount Sinai
When: Saturday morning

Richie was working all weekend this weekend, and things were pretty hectic. He had a full patient allocation and a few of his patients were quite seriously ill and needed close monitoring. Not severe enough to warrant admission to the PICU, but the next step down. Helping kids was the reason he wanted to get into Pediatrics, but it was never easy to see little people sick or in pain. He knew that it was his job to try to help them, though, which was the rewarding part. He knew what it was like to be a kid in hospital, and over the years, the doctors and nurses who had cared for him had been amazing. He had a lot of good role models, so he hoped he was just as helpful to his own patients these days.

He arrived at little Tanner's room with a smile at his guardians, Kevin and Quentin. "He-llo. We have progress. Pathology has been kind to us," he revealed, holding Tanner's medical record in his hand and reading over the latest set of nursing notes to see what was progressing on the most recent rounds. But, as always, his attention was first zeroed in on the child and he went over to Tanner and softly stroked his little forehead. Tanner was conscious, but groggy. He hadn't really come through the anesthetic very well and he was still running a pretty mean temperature. You knew when a child was even too ill to cry that it was serious business. Richie had ordered him on antibiotics and a nasogastric tube, which wasn't nice for parents to see, but necessary in this case.

"Hi there, little man. We need to get these pukies sorted, don't we?" Tanner had been vomiting throughout the morning. Richie had suspected Tanner had a bowel obstruction as soon as he presented and was examined. Normally, it would first be attempted to treat it conservatively, but when they sent him for a CT, they discovered it was a nasty obstruction and if it wasn't fixed surgically, his life could be in danger. Richie hadn't hesitated in ordering the surgery and Nate signed off on it. While they were in sorting out the issue, they had taken biopsies to try to find out what was causing the little lad's stomach issues that he had a history of since birth. The heartbreaking part was, the abuse that his mother had been inflicting on him may have been aggravating any inflammation he had inside, causing it to exacerbate. It was such a sad situation.

He was still stroking Tanner's hair soothingly when he started to explain things to Kevin and Quentin. "The good news is that it's not cancer, and there's no cancerous cells whatsoever. That was the biggest red flag we were looking at, given his ongoing issues. The bad news is, when they were in, they had to resection. It was the only way to remove the obstruction, but that's okay. He'll heal. What the biospy results have shown is an inflammatory bowel disease called Crohn's. There's no cure, unfortunately."

Comments

[lifeinthefastlane]

Having a sick kid in your care was never an easy thing. And for Kevin, it wasn't because it was too hard. It wasn't because he didn't want to put in the effort. It was because it was absolutely heartbreaking seeing a tiny person struggle with being in pain and not understanding why. Kevin and Quentin adored the little boy, and both of them wanted to be able to raise him, but while Kevin, at first, had gotten his hopes up that they'd be able to legally adopt him, life had shown him quickly that things didn't always work out the way you hoped they might or thought they would, and the most money, best lawyers, and highest hopes in the world couldn't fix it. They couldn't guarantee that the judge would ultimately decide that Tanner's safest place was with them. They could still decide that a couple of young unmarried guys weren't prepared to be dads... despite the fact that they had been in everything but name... and even that wasn't totally true, since Tanner, curled up in Quentin's arms one night, had called him "Daddy." It wasn't easy. It wasn't as easy as just waiting and seeing, because as much as they were both trying to take this day by day, this little boy had stolen their hearts. And if they took him away from them, they'd both be heartbroken, no matter how much they'd tried not to get their hopes up.

When Richie came in, Kevin's eyes immediately went to the young doctor hoping that there would be good news. There'd been so much bad of late... so many questions about little Tanner and his health. All Quentin and Kevin wanted was to know as much as they could to take care of him the best way possible. He needed help and love, and they were willing to give that in bucketloads. Kevin sat close by Tanner's bed with Quentin at his side, their hands linked together. Their relationship in itself hadn't been very easy, either. It had gotten off to a hell of a rocky start, but through it, Kevin had learned so much about how to love... How to love with his heart and not his wallet. Quentin didn't want to be kept. He didn't want to be the other half of a sugar daddy relationship. He wanted to be loved as an equal, and Kevin had learned to do that every step of the way, with little Tanner there with them. It had been a major learning curve, but they'd navigated it together so far, not without their mistakes, but the fact they were still together meant a hell of a lot to Kevin. "What does that mean for him?" he asked when Richie was explaining. "For Tanner?"

[breakthesilence]

It had been a difficult wait on pathology results. Before then, no doctor would be willing to just say what it could be, what they hoped it wouldn't be. Though, Richie had been straight with them when Tanner was being prepped for surgery that there was a chance the symptoms could be a sign of cancer. He explained that he hadn't wanted to scare the living shit out of them, but it was his responsibility to at least make them aware it was but one possibility so they could have time to process it. The surgery had been quite long, so of course they began to think the worst and stress. Worry themselves sick even. It turned out the surgery was just an intricate process with Tanner's gastrointestinal tract being very small, and the blockage in a place that needed extra care. Now they were learning he needed a resection, which sounded terrifying, though Richie wasn't making with scary references or anything. He was being open and clear here.

Quentin was watching the bedside manner too. Richie had it in bucketloads. They had seen that the moment he came to examine Tanner the night they brought him in. The poor little boy had been in horrific pain, screaming because of it, and throwing up. He also had a really high temperature and hadn't pooped in days. Panic had them calling an ambulance, and ultimately, it was the best call to make. Richie was so sweet with his patients. Not just Tanner, but all of them. Even the kids in the hospital that weren't his patients. He was placid and tender, would often sit to be at their level, made sure he was soothing and gentle while he examined them or administered any sort of treatment. When he talked to adults, he was respectful and spoke with clarity, though also in a casual laid back way so it wasn't like he was just spewing medical terms at them. When he spoke to kids, it was how they could respond to him and understand he was there to help them. With Richie and Nate taking care of Tanner, Quentin realised his worry could ease just a little. At hearing it wasn't cancer, he heaved an audible and visual sigh of relief. "Can you tell us more about that? I've heard of it, but I don't know what it is. Is that why he's been so sick on and off? Can it be treated? Why do you think he's still throwing up? I'm just concerned because it's painful for him when he does."

[thankfuckforlife]

Richie did sit now. There were treatment stools in all the rooms on the kids' ward because doctors did try to be on a child's level wherever they could. He had been wheeling it up to Tanner's bedside opposite to where Kevin and Quentin were sitting so he could both take Tanner's obs and talk more to them about what this would mean now. "Okay, Crohn's Disease is chronic illness that causes ongoing inflammation throughout any of the GI tract. It is characterised by flare-ups, but yes, it is very treatable, however not curable. It can actually occur through any part of the GI tract, right from up in the oesophagus, to right down to the anus. It's also what we call systemic. It's widespread, over the entire body, affecting other parts beyond the GI tract. It can cause growth failure in children. It can cause weight loss, mouth ulcers, fevers, sweats. Smoking can exacerbate it, so if he had anyone smoking around him or whilst he was in-utero, it may have given him a higher predisposition to falling victim to it. The big killer here? Stress can make it worse and seriously worse. This little guy has been shipped from pillar to post, in and out of care of strangers, suffered abuse, been in very poor environments. What this diagnosis will do will actually force the hand of the services to have him adopted ASAP to be able to reduce his levels of stress to encourage healing and recovery. This may be where you guys are in a prime position."

He put Tanner's file down so he could check his blood pressure. "As to symptoms, everything he has been experiencing are classic signs. Nate has actually been querying this form of illness for a few months now and, as you know, we were preparing to scope him anyway and then this happened. It's an incredibly complex illness, so what I'm not going to do is throw every single fact at you about it, or tell you every single thing that might happen with it. I'll focus on Tanner's presenting symptoms and what our first port of call with treatment will be. Tanner's been having some of the systemic via fevers and sweats, but he has had a lot of bowel issues. Bouncing between diarrhoea and constipation, having a lot tummy pain, gas, loss of appetite, increased bowel sounds. That was how I knew right up he had an obstruction. He had no bowel sounds. A blockage, in essence, sort of grinds the gut to a hold, like a traffic jam. Everything stops. Tanner will have ongoing belly issues, and you have to be aware at times there may be blood in his poop. If that seems to be a lot, you need to get him back to us. We don't want bleed-outs if we can help it. With something like this, we don't talk of treatment but of management, and that involves adopting a regime for him. The throwing up now is a post-operative reaction to the anesthetic. He has nothing inside to bring up, but knocking a kid out for a major surgery can be rough on them."

[lifeinthefastlane]

Kevin's hand tightened just that little bit around Quentin's as he braced himself to hear what the news meant. He knew that not having cancer was incredibly good news, but Crohn's was something that Kevin didn't know much about, and it still sounded scary if it was already making Tanner need surgery, even as small as he was. The key here was that Kevin and Quentin be united to protect and care for Tanner the best way possible. It didn't matter that there was still a very valid chance that he may not end up in their care when all was said and done. They couldn't be sure of it, and Kevin didn't want to stake his hopes on it, but he also didn't want to let it be for lack of trying if Tanner didn't end up staying with them. That wasn't the question right now, though. The question at hand now was Tanner's health. He had a chronic illness and they weren't promised to be his parents forever, but they were his foster parents for now, which meant they needed to learn how best to care for the little boy, no matter what. Even if they were only caring for him a little while, they would give him the best damn care they could. As Richie explained to them what all of this meant, Kevin tried to take it all on board. The little boy's illness had been something he'd probably been dealing with all along without being cared for properly because his mother had cared more about her drug habit than him, and the cunt had probably made it worse, too. He couldn't be angry, though. Tanner sensed their emotions, and he would get agitated... And Kevin wouldn't give the bitch the ability to hurt Tanner anymore than she already had.

"So some of it will be very similar to what we've been seeing so far, but there's other things, too. So... When it comes to helping to manage the illness, we keep track of how his stomach is, but... I mean, does he need to adopt a particular sort of diet? Or medication?" He was taking in everything that Richie was saying, but there was a lot to take in. Kevin reached out ever so gently to ruffle Tanner's hair, his eyes sad, but filled with love. Tanner was still bleary eyed, and it seemed to just confirm that much more what Richie was saying about the anesthesia. By now, an adult would've pretty well shaken it off, but Tanner's tiny body just wasn't that resilient. "We're sorry you don't feel good, buddy," Kevin told him. "Doctor Richie and Doctor Nate are finding out what makes your tummy hurt." The little boy's eyelids seemed heavy as he looked at Kevin and blinked. If there was one thing both Kevin and Quentin wanted, it was to provide Tanner with affection, so he'd know he was loved. "A lot of it's going to keeping an eye on him... on when and if he poops, and if there's blood. if he's off his appetite and all that stuff... I'm assuming he'll be in a lot of pain healing from surgery... Anybody would be, but can we expect it to be more painful with you guys having needed to do the resectioning?"

[thankfuckforlife]

"Yes, and yes. And also yes to other things too," Richie confirmed with a nod. In addition to being a short-ass, Richie had also been born left-handed so when he wrote his clinical notes, it always looked awkward because he had to write in a way that didn't smudge what he had just written. He marked down Tanner's blood pressure, temp, and O2 sats. "They were going to try to fix the blockage with a laparoscopic procedure, but when they realised he needed the resection, it was elevated to open. Which is hard and he's going to feel sore and unwell until he heals. We've already got him on the max dose of antibiotics, so what I'm going to do is order another five days of that. That will mean he will need to stay in here because they're IV. As long as he is still vomiting, we can't administered anything oral for him. When he starts to be able to keep things down again, we'll put him on a clear fluid diet, then it will move up to free fluids, and then solids. What we'll do is rather than the standard three meals a day, I want to try him on six smaller meals plan. We'll have a dietician come in and discuss all this with you and they will draw up a meal plan with a schedule when to feed him, and what to feed. One big thing we want to focus on is his fluid intake. When he has diarrhoea, fluids and electrolytes deplete quicker. That happens for anyone when they're sick with a viral bug. Because he's outputting more than he's taking in, you need to balance out his intake. If he's not eating, fluids. If he is eating, fluids. Water, juice but avoid citrus juices because it can make an inflammation worse. We want to try to keep the dairy at a minimum, so we're going to recommend switching to something like soy, almond or rice milk for him. It's a little less harsh on an upset tummy. Fruit is very good because it contains a lot of fibre. Went to try to bulk up what's inside him and it will work to help keeping him regular. If we can get his bowels to regulate, it means less taxing on them and therefore less aggravation on the inflammation."

He stopped writing when Tanner was trying to get his pen off him. It had a little reservoir or water in it with a boat that swam up and down inside. He gave it to the little boy with a smile. "See the boat, Tanner? That's a sailboat with a little flag. Turn it this way, it floats back up the river." He kept his hand resting on Tanner's arm just in case the toddler decided he wanted to shove the pen in his mouth, as toddlers did. "Guys, I respect this is a hell of a lot of information to take in, but a lot of it is very basic and will be easy to follow. When we say a special diet, that's not really an accurate description because what we will do is remove a lot of what he would normally eat and cut it to down some basic natural things that we know his tummy doesn't need to work as hard on to digest. If that makes sense. We don't look to add special foods, but rather subtract foods and drinks that are less beneficial for him. Just always have water for him. Bottles, sippy cups, whatever he will take, keep some in the fridge with water all the time. Hydration is a huge key here. I'm also going to trial him on two meds for Crohn's, and an iron supplement for the anemia. He's already on IV hydrocortisone, which is a steroid to reduce the inflammation. I can't emphasise enough how important it is to keep his stress at a bare minimum. Preferably none at all. If you guys are having a crap day or having a bitch fight, don't bring it back into his presence. Children his age absorb everything. His health really does depend on it now. I do also need to discuss with you that if we can't get him eating in say, the next three to five days, we're going to have to put him on what they call PEG feeding. That stands for percutaneous endoscopic gastrostomy. It's a tube inserted into his stomach and a nutritional liquid supplement will feed him directly into that. This is to give the GI tract a rest and helps the healing process, and aims to encourage weight gain. But we'll try to get him on the right track first."

[breakthesilence]

It was a wonder Quentin didn't end up with a dislocated neck with all the nodding he was doing as Richie spoke. It was a lot to take in, but he was finding as he listened that he understood everything that was being said. It wasn't anything crazy-clinical to follow, and a lot of it made sense. Plus, they would have a dietician to help, so that was good to hear. It seemed like a step-by-step process, and for now Tanner would be in for probably a week more, at the very least. He was in good hands here, and even if it was confronting seeing tubes up his nose and IV lines in his tiny little hands, it was all to help him. When they had gone to him in Recovery, that had been awful. He was still unconscious, on oxygen and monitors, and the surgeon told them that Tanner did well in the surgery, but explained it had been more intense than first thought. Tanner woke up vomiting and nearly aspirated, so there was a terrifying few minutes with that. The staff were amazing, though. He had the best care he possibly could here. "He likes fruit. When he's up to eating, he always likes fruit. He will have water too. I know some kids aren't fans, but he seems to take it when we give it to him."

Richie was emphasising seriously how important it was that Tanner's stress levels stayed down. "So... in your professional opinion, that is, you think the abuse and being put through the system in the way he has been is probably what got him to being this sick? He's been sick on and off since we got him. Literally what the social worker told us was he wasn't a big eater and sometimes had tummy troubles. We know he's been a patient here a lot, but do you think all that is what has led here? As soon as we knew something was really wrong, we just called the ambulance. Part of it was panic, but there was definitely a part that we've already gotten to know him and can see the signs of when he's normal for him, or really not normal. The day or two before he got really worse, he was so lethargic. He just wanted to be held and cuddled. If we put him down, he would cry, and of course, that was friggen heartbreaking. I don't know, sometimes it just feels like he's scared it we put him down, we're going to give him away again. He's so young, but I think that's what he is expecting because any time he trusts someone, they're gone and he's given to strangers again. We didn't want to fall into the trap of just going all 'Oh, he's a victim of child abuse, so that's normal behaviour'. We knew it wasn't."

[lifeinthefastlane]

This was a hell of a lot of information, but Kevin also knew that Richie would make sure they had it all down in writing before they took Tanner home. The staff here weren't exactly in the habit of sending you home with a diagnosis, but no idea of what to expect, and Kevin was grateful, because when you got a ton of information like this, it usually took quite a while to navigate through it all and really put it to memory. "So we keep him on the smaller meals, even when he can eat regular food, because it's easier for his digestive system to process smaller amounts of food at a time?" Kevin guessed, looking from Tanner to where Richie was sitting, then back over to Quentin. "He does like fruit," Kevin said by way of agreement with his boyfriend. "Apples are his favorite, with the skin off and chopped up in bite size pieces." He and Quentin had learned early on how much Tanner liked those. Sometimes with a bit of peanut butter, because there'd been concerns when he wasn't eating well about getting some protein in, too. "We've been making an extra effort to keep him hydrated because of the bladder problems he's had, too. Right, buddy? We try to keep you drinking lots of water."

"Nate mentioned that because of the abuse, he probably actively tried not to poop and pee... And that had to have been rough on his little system, too. But that's exactly what they told us. Maybe if we can get him on a management plan that helps him with the pain, and a diet that doesn't hurt his tummy, it'll help with his appetite, too. I'd be off my food, too, if it made me feel yuck every time I tried to eat something. But like Quentin said, it's a matter of knowing him. We're learning his cues. Sure, he's going to respond differently because of having been abused in the past. But while that's the difference in behavior sometimes, there's a difference in him behaving a certain way because he's upset and because he's in pain and not feeling good. We've learned him pretty well. That's probably our biggest fear is just that he'd end up with a family who chalk his pain up to his past instead of his body being sick, and don't realize what's really wrong with him. We don't know everything. We just try to pick up on what he's telling us when he can't tell us things." He watched Tanner focus on the pen Richie had, and it seemed a welcome distraction. Even with his tired eyes, he pulled his focus in on it, and Kevin had to smile at that. "That's a really cool pen Doctor Richie has, huh, buddy?"

[thankfuckforlife]

Richie had already been noting down points in Tanner's file of what he was covering with Kevin and Quentin so that he could have it all typed up for them to keep with them as reference. But he was happy for the little boy to have his pen, and it was lucky he had a spare, because Tanner soon dropped off to sleep holding the pen in his little hand against his chest. His system and body had been through the wringer, and at this point in time, he was a very sick little boy. It was why he was in the high dependency wing of the children's unit. He would be until he started to be able to tolerate food orally. "I absolutely in my professional opinion think that for a child of this age with a history of abuse and emotional stress is this ill with a condition classically exacerbated by stress, it is the stress that has gotten the condition to this severity. One step further, if the blockage was a little more complex, he would have been put on a stoma. A colostomy bag, either temporarily or permanently if there was extensive damage to his bowel. That is the professional opinion of Dr Richie. Now I'm going to take my doctor hat off and speak to you off the record as Richie the human being. If you are, at all, considering adoption for Tanner, I would say to now, today or tomorrow, go home and start getting all your paperwork to be adoptive parents drawn up and filed. Because as soon as the services receive Nate and mine's reports on Tanner condition and medical history, along with operation reports and his treatment, plan I guarantee his mother's parental rights will be severed immediately. This could all happen within in a few days. Upon receipt of a copy of the reports, Tanner's attorney may likely have a result in a turn-around of 24 to 48 hours. Which means he could be an official Ward of the State in no time. You have to have all your ducks in a row, because his age and now diagnosed lifelong chronic illness means he will be prioritised to find permanent guardians who have the ongoing capacity to care for him."

He had his other pen out, this time with Elmo's head on the end of it and continued his notes. "Do either of you know Billy or Ajay?" he asked as an afterthought, still once again off the professional record. "Talk to Ajay if you can. That's all I can say without breaching any confidentiality, but if you can, it will be helpful. I also want to refer you and Tanner a social worker through the hospital here. Who just happens to be Ajay's older brother, but he works with sick children who have an impacting diagnosis where there will be a longer-term recovery. I think if you engage with Travis, it will be another report that can go in your favour through the adoption process. But that aside, he is very good with young children and I think you'll need the support in these early days. It's not easy. It's hard to see children so sick, and it's going to be a learning curve. No matter how much you have your head wrapped around everything, it will all depend on how Tanner responds. We may encounter further issues with his feeding, he might have more complications. Travis will be able to support you with things like coping strategies."

[breakthesilence]

A look of horror had appeared on Quentin's face when Richie outlined just how close Tanner could have come to ending up with a stoma. He knew what that was, and it was horrific to think of a toddler having to deal with something like that. At first, he was speechless. He had been processing everything as well as he could, along with keeping an eye on Tanner and attempting to stay calm. But now Tanner had dozed off on them again still with his pacifier in his mouth, he didn't have to hide his emotions so much. He just shook his head and put his hand over his eyes for a few moments, trying to just work through the really difficult parts of all this. He was dealing the best he could, but his coping mechanisms weren't what they used to be. Not to mention the fact he was exhausted. He hadn't left the hospital since Tanner was brought in. When they had left in the ambulance, he didn't just shove some of Tanner's things into a backpack, he shoved some clothes for them in there too. Richie was being beyond helpful here, above and beyond the scope of his job. Quentin appreciated that, as he was giving them a heads-up of what to do right now to give them the best chance of being allocated Tanner's legal guardians and hopefully be able to adopt him. They knew Dani was cutthroat and she had been since taking on Tanner's case, but she had been getting a lot of runaround from Tanner's mother's lawyers, sending bullshit correspondence how she was trying to rehabilitation and stay clean to be the best mom she could be for her little boy. Dani had warned them that, as much as she was going to keep fighting, a sympathetic judge might rule in favour of the mother. Now Richie was here telling them that was probably less likely now.

He hand left his eyes and he rested his fingers against his lips. "Ajay? I sort of know Ajay..." He paused and cleared his throat. "I used to see boss, Gen. At least, when he worked with Gen. She's told me since that he doesn't, and explained about Billy, who I haven't met. I don't know if Kevin knows them. I know of them, but I also know Billy's been getting treatment for cancer and they were getting married? She told me Ajay was getting married. You think he can help because he's related to Travis, or is there some other link there? Wait, don't answer. I know you can't answer the why. We'll ask whoever the hell we can for help. It can't go on like this. He can't keep being in this much pain. He doesn't understand why he's hurting. He doesn't understand that it's okay not to be scared he's going to be taken away? And you know one of the worst parts? We can't tell him it will be okay and we won't go away, because we just fucking don't know."

[lifeinthefastlane]

When Quentin's hand left his, Kevin took that opportunity to rub his partner's back softly. These were the times that it truly hit home for him just how fucking worthless his credit cards were. They could buy comforts. They could give you a big screen TV instead of a smaller one. They could pay bills. The money Kevin had could keep them up for life. He could make it so Tanner would never wear the same clothes twice and he'd have a really expensive sports car the minute he was old enough. But all of that was fucking worthless, and while he knew that just throwing money at situations wasn't beneficial anymore, and it wasn't fair to Quentin, and it just wasn't the right thing to do... maybe it was now that it was truly hitting him just how little money truly meant in the grand scheme of things. Tanner was in pain. A swipe of Kevin's credit card wasn't going to take his pain away. It wasn't going to sway a judge's decision of whether to place him with Kevin and Quentin or not. The expensive comforts weren't what mattered. A roof over their heads, food, and medical care were the main things, but even more than that, love and comfort, and Kevin had found that giving those to both Tanner and Quentin was simultaneously the most fulfilling and most heartbreaking thing he'd ever done, and he wouldn't trade it for the world. He would lay his heart on the line for these two beautiful people every single time, no matter how much it got broken and bruised. He loved them. They were his family, no matter what the courts might say, and he would do whatever he could. It was good, at least, to know that they had a much better chance of getting his mother's parental rights terminated.

"I know Billy through his brother, Jude," Kevin replied. "But I don't know Ajay personally. When I used to go out, Jude and I went to some of the same places and we were pretty good friends. But I'm sure a counselor would be a good thing. Quentin and I both really want to take care of this little guy, and the more we know about how to do that best, the better. Not just from the medical perspective, but from the psychological perspective, too. And I know it's important to take care of ourselves and each other, too. But when he gets sick, it's hard to think about anything other than him and making sure that he's okay and his needs are met, you know? But Quentin's right. Anyone who can help, we're more than willing to talk to. We want to help him, whatever it takes." Quentin's words cut deeply, though, and Kevin's hand just continued to rub gently at the other man's back. It hurt like hell that they couldn't just promise Tanner he wasn't going anywhere. They didn't know that. All they could do was try. "We'll get the paperwork in order at least. Like you said, if they terminate her rights, we can file right away." His eyes went back to where Tanner was sleeping, and his heart felt near to bursting at the sight. "Fuck, he's just so little. How could you not want to keep him safe?"